Medical List Form
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Complete Medical List Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1
2PATIENT’S NAME:________________________________Please list your current medications on the Medical List form
provided in your packet. Be sure to spell correctly and list the dosage and amount of medication you are taking as
listed on your prescription bottle. Bringing in your medications for our review would be greatly appreciated.
REVIEW OF SYSTEMS
Y N
Y N
Y N
GENERAL
STOMACH
NEUROLOGICAL
Headache
Trouble swallowing
Stroke
Lethargy/Weakness
Heartburn/Indigestion
Seizures
Chills/Night sweats
Change in bowel habits
Head injury
Fever
Loose Stool/diarrhea
Memory loss
Fainting spells/unconscious
Black/Bloody Stools
Confusion
Weight loss
Frequent stomach pain
Trouble speaking
Dizziness
Vomiting blood
Trouble swallowing
EYES
Constipation
Unsteady gait
Wears glasses
Irritable bowel
Trouble walking
Eyesight worsening
Ulcers
Arm/leg weakness
Double vision
Stomach/bowel cancer
Arm/leg tingling
Eye pain
KIDNEY PROSTATE
Arm/leg numbness
EARS/NOSE/THROAT
Frequent voiding
PSYCHIATRIC
Deafness
Burning on urination
Nervous breakdown
Noise in ears
Pus/blood in urine
Panic attacks
Congestion/sneezing
Trouble starting urination
Cry often/depressed
Sinus trouble/hay fever
Dribble with cough/sneeze
Worry a lot
Nose bleeds
Loss of urine control
Considered suicide
Sore throat or tongue
Prostate disease/cancer
Loss of interest in eating
Hoarse voice
Sexual difficulty
Anxiety/tension
Dental problem
Loss of energy/fatigue
SKIN
Rashes
HEART
ENDOCRINE
Chest pain with exertion
Birthmarks
Unwanted weight change
Heart attack
Sores
Change in skin
Heart murmur
Dry/oily skin
Breast discharge
Heart racing/palpitations
Hair growth/loss
Excessive thirst
Irregular heart beat
Excessive tiredness
MUSCLE/BONE
Mitral valve prolapsed
Back pain
BREAST/MENSTRUAL
High blood pressure
Neck pain
Endometriosis
Swollen feet/ankles
Back surgery
Are you pregnant?
Heart valve replacement
Arthritis
Irregular menstrual
period
Atrial fibrillation
Fibromyalgia
Breast discharge
LUNG
Aching muscles/joints
Lumps in breast
Lung cancer
Shoe lift or brace
SLEEP
Shortness of breath
Bone/joint injury
Dreams/sleep walk
Chest pain
Osteoporosis
Legs twitch
Coughing up phlegm
HETATOLOGIC
Insomnia
Cough up blood
Blood disease
Daytime drowsiness
Wheezing/cough
Enlarged glands
Snores
Pneumonia
Bleed/bruise easily
Breath holding/gasping
Anemia/low blood
Restless sleep
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Parent category: Medical